Agency Information Collection Activities: Proposed Request and Comment Request, 15412-15414 [2017-06025]

Download as PDF 15412 Federal Register / Vol. 82, No. 58 / Tuesday, March 28, 2017 / Notices SOCIAL SECURITY ADMINISTRATION [Docket No: SSA–2017–0013] Agency Information Collection Activities: Proposed Request and Comment Request The Social Security Administration (SSA) publishes a list of information collection packages requiring clearance by the Office of Management and Budget (OMB) in compliance with Public Law 104–13, the Paperwork Reduction Act of 1995, effective October 1, 1995. This notice includes revisions of OMB-approved information collections. SSA is soliciting comments on the accuracy of the agency’s burden estimate; the need for the information; its practical utility; ways to enhance its quality, utility, and clarity; and ways to minimize burden on respondents, including the use of automated collection techniques or other forms of information technology. Mail, email, or fax your comments and recommendations on the information collection(s) to the OMB Desk Officer and SSA Reports Clearance Officer at the following addresses or fax numbers. (OMB), Office of Management and Budget, Attn: Desk Officer for SSA, Fax: 202–395–6974, Email address: OIRA_Submission@omb.eop.gov (SSA), Social Security Administration, OLCA, Attn: Reports Clearance Director, 3100 West High Rise, 6401 Security Blvd., Baltimore, MD 21235, Fax: 410–966–2830, Email address: OR.Reports.Clearance@ssa.gov Or you may submit your comments online through www.regulations.gov, referencing Docket ID Number [SSA– 2017–0013]. I. The information collections below are pending at SSA. SSA will submit them to OMB within 60 days from the date of this notice. To be sure we consider your comments, we must receive them no later than May 30, 2017. Individuals can obtain copies of the collection instruments by writing to the above email address. 1. Request for Waiver of Overpayment Recovery or Change in Repayment Number of respondents Modality of completion Notice—20 CFR 404.502–404.513, 404.515, 416.550–416.570, and 416.572—0960–0037. When Social Security beneficiaries and Supplemental Security Income (SSI) recipients receive an overpayment, they must return the extra money. These beneficiaries and recipients can use Form SSA–632–BK to take one of three actions: (1) Request an exemption from repaying, as recovery of the payment would cause financial hardship; (2) inform SSA they want to repay the overpayment at a monthly rate over a period longer than 36 months; or (3) request a different rate of recovery. In the latter two cases, the respondents must also provide financial information to help the agency determine how much the overpaid person can afford to repay each month. Respondents are overpaid beneficiaries or SSI recipients who are requesting: (1) A waiver of recovery of an overpayment, or (2) a lesser rate of withholding. Type of Request: Revision of an OMBapproved information collection. Average burden per response (minutes) Frequency of response Estimated total annual burden (hours) 400,000 100,000 44,000 500,000 1 1 1 1 120 45 120 5 800,000 75,000 88,000 41,667 Totals ........................................................................................................ sradovich on DSK3GMQ082PROD with NOTICES Waiver of Overpayment (Completes Whole Paper Form) .............................. Change in Repayment (Completes Partial Paper Form) ................................ Regional Application (New York Debt Management) ...................................... Internet Instructions ......................................................................................... 1,044,000 ........................ ........................ 1,004,667 2. RS/DI Quality Review Case Analysis: Sampled Number Holder; Auxiliaries/Survivors; Parent; and Stewardship Annual Earnings Test— 0960–0189. Section 205(a) of the Social Security Act (Act) authorizes the Commissioner of SSA to conduct the quality review process, which entails collecting information related to the accuracy of payments made under the Old-Age, Survivors, and Disability Insurance Program (OASDI). Sections 228(a)(3), 1614(a)(1)(B), and 1836(2) of the Act require a determination of the citizenship or alien status of the beneficiary; this is only one item that we might question as part of the Annual Quality review. SSA uses Forms SSA– 2930, SSA–2931, and SSA–2932 to establish a national payment accuracy rate for all cases in payment status, and to serve as a source of information VerDate Sep<11>2014 17:14 Mar 27, 2017 Jkt 241001 regarding problem areas in the Retirement Survivors Insurance (RSI) and Disability Insurance (DI) programs. We also use the information to measure the accuracy rate for newly adjudicated RSI or DI cases. SSA uses Form SSA– 4659 to evaluate the effectiveness of the annual earnings test, and to use the results in developing ongoing improvements in the process. About twenty-five percent of respondents will have in-person reviews and receive one of the following appointment letters: (1) SSA–L8550–U3 (Appointment Letter— Sample Individual); (2) SSA–L8551–U3 (Appointment Letter—Sample Family); or (3) the SSA–L8552–U3 (Appointment Letter—Rep Payee). Seventy-five percent of respondents will receive a notice for a telephone review using the SSA–L8553–U3 (Beneficiary Telephone Contact) or the SSA–L8554–U3 (Rep PO 00000 Frm 00099 Fmt 4703 Sfmt 4703 Payee Telephone Contact). To help the beneficiary prepare for the interview, we include three forms with each notice: (1) SSA–85 (Information Needed to Review Your Social Security Claim) lists the information the beneficiary will need to gather for the interview; (2) SSA–2935 (Authorization to the Social Security Administration to Obtain Personal Information) verifies the beneficiary’s correct payment amount, if necessary; and (3) SSA–8552 (Interview Confirmation) confirms or reschedules the interview if necessary. The respondents are a statistically valid sample of all OASDI beneficiaries in current pay status or their representative payees. Type of Request: Revision of an OMBapproved information collection. E:\FR\FM\28MRN1.SGM 28MRN1 15413 Federal Register / Vol. 82, No. 58 / Tuesday, March 28, 2017 / Notices Number of respondents Modality of completion Average burden per response (minutes) Frequency of response Estimated total annual burden (hours) SSA–2930 ........................................................................................................ SSA–2931 ........................................................................................................ SSA–4659 ........................................................................................................ SSA–L8550–U3 ............................................................................................... SSA–L8551–U3 ............................................................................................... SSA–L8552–U3 ............................................................................................... SSA–L8553–U3 ............................................................................................... SSA–L8554–U3 ............................................................................................... SSA–8552 ........................................................................................................ SSA–85 ............................................................................................................ SSA–2935 ........................................................................................................ SSA–8510 (also saved under OMB No. 0960–0707) ..................................... 1,500 850 325 385 95 35 4970 705 2350 3850 2350 800 1 1 1 1 1 1 1 1 1 1 1 1 30 30 10 5 5 5 5 5 5 5 5 5 750 425 54 32 8 3 414 59 196 321 196 67 Totals ........................................................................................................ 17,700 ........................ ........................ 2,525 3. Electronic Records Express—20 CFR 404.1512 and 416.912—0960–0753. Electronic Records Express (ERE) is a Web-based SSA program which allows medical and educational providers to electronically submit disability claimant data to SSA. Both medical providers and other third parties with connections to disability applicants or recipients (e.g., teachers and school administrators for child disability applicants) use this system once they complete the registration process. SSA employees and State agency employees request the medical and educational records collected through the ERE Web site. The agency uses the information collected through ERE to make a determination on an Application for Benefits. We also use the ERE Web site to order and receive consultative examinations when we are unable to collect enough medical records to determine disability findings. The respondents are medical providers who evaluate or treat disability claimants or recipients, and other third parties with connections to disability applicants or recipients (e.g., teachers and school administrators for child disability applicants), who voluntarily choose to use ERE for submitting information. Type of Request: Revision of an OMBapproved information collection. Modality of completion Number of respondents Frequency of response Average burden per response (minutes) Estimated total annual burden (hours) ERE .................................................................................................................. 5,376,998 1 10 896,166 II. SSA submitted the information collections below to OMB for clearance. Your comments regarding these information collections would be most useful if OMB and SSA receive them 30 days from the date of this publication. To be sure we consider your comments, we must receive them no later than April 27, 2017. Individuals can obtain copies of the OMB clearance packages by writing to OR.Reports.Clearance@ ssa.gov. 1. State Mental Institution Policy Review Booklet—20 CFR 404.2035, 404.2065, 416.635, & 416.665—0960– 0110. SSA uses Form SSA–9584–BK: (1) To determine if the policies and practices of a state mental institution acting as a representative payee for SSA beneficiaries conform to SSA’s regulations in the use of benefits; (2) to confirm institutions are performing other duties and responsibilities required of representative payees; and (3) as the basis for conducting onsite reviews of the institutions and preparing subsequent reports of findings. The respondents are state mental institutions serving as representative payees for Social Security beneficiaries and SSI recipients. Type of Request: Revision of an OMBapproved information collection. Number of respondents Frequency of response Average burden per response (minutes) Estimated total annual burden (hours) SSA–9584–BK ................................................................................................. sradovich on DSK3GMQ082PROD with NOTICES Modality of completion 69 1 60 69 2. Statement of Death by Funeral Director—20 CFR 404.715 and 404.720—0960–0142. When an SSAinsured worker dies, the funeral director or funeral home responsible for the worker’s burial or cremation completes Form SSA–721 and sends it to SSA. VerDate Sep<11>2014 17:14 Mar 27, 2017 Jkt 241001 SSA uses this information for three purposes: (1) To establish proof of death for the insured worker; (2) to determine if the insured individual was receiving any pre-death benefits SSA needs to terminate; and (3) to ascertain which surviving family member is eligible for PO 00000 Frm 00100 Fmt 4703 Sfmt 4703 the lump-sum death payment or for other death benefits. The respondents are funeral directors who handled death arrangements for the insured individuals. Type of Request: Revision of an OMBapproved information collection. E:\FR\FM\28MRN1.SGM 28MRN1 15414 Federal Register / Vol. 82, No. 58 / Tuesday, March 28, 2017 / Notices Modality of completion Number of respondents Frequency of response Average burden per response (minutes) Estimated total annual burden (hours) SSA–721 .......................................................................................................... 703,638 1 4 46,909 credit the earnings to the correct individual and SSN. We send the SSA– 4156 to the employer to: (1) Identify the employees involved; (2) resolve the discrepancy; and (3) credit the earnings to the correct SSN. The respondents are 3. Employee Identification Statement—20 CFR 404.702—0960– 0473. When two or more individuals report earnings under the same Social Security Number (SSN), SSA collects information on Form SSA–4156 to employers involved in erroneous wage reporting for an employee. Type of Request: Revision of an OMBapproved information collection. Modality of completion Number of respondents Frequency of response Average burden per response (minutes) Estimated total annual burden (hours) SSA–4156 ........................................................................................................ 4,750 1 10 792 4. Employee Work Activity Questionnaire—20 CFR 404.1574, 404.1592—0960–0483. Social Security Disability Insurance (SSDI) beneficiaries and SSI recipients qualify for payments when a verified physical or mental impairment prevents them from working. If disability claimants attempt to return to work after receiving payments, but are unable to continue working, they submit the SSA–3033, Employee Work Activity Questionnaire, so SSA can evaluate their work attempt. SSA also uses this form to evaluate unsuccessful subsidy work and determine applicants’ continuing eligibility for disability payments. The respondents are employers of SSDI beneficiaries and SSI recipients who unsuccessfully attempted to return to work. Type of Request: Revision of an OMBapproved information collection. Modality of completion Number of respondents Frequency of response Average burden per response (minutes) Estimated total annual burden (hours) SSA–3033–BK ................................................................................................. 15,000 1 15 3,750 5. Request for Medical Treatment in an SSA Employee Health Facility: Patient Self-Administered or Staff Administered Care—0960–0772. SSA operates onsite Employee Health Clinics (EHC) in eight different States. These clinics provide health care for all SSA employees including treatments of personal medical conditions when authorized through a physician. Form SSA–5072 is the employee’s personal physician’s order form. The information we collect on Form SSA–5072 gives the nurses the guidance they need by law to perform certain medical procedures and to administer prescription medications such as allergy immunotherapy. In addition, the form allows the medical Number of respondents Modality of completion SSA–5072 ............................................................................ Annually ............................................................................... SSA–5072 ............................................................................ Bi-Annually ........................................................................... Average burden per response (minutes) Number of responses 1 25 5 2 75 2 150 5 13 100 ........................ ........................ ........................ 15 Dated: March 22, 2017. Naomi R. Sipple, Reports Clearance Officer, Social Security Administration. [FR Doc. 2017–06025 Filed 3–27–17; 8:45 am] BILLING CODE 4191–02–P VerDate Sep<11>2014 17:14 Mar 27, 2017 Jkt 241001 PO 00000 Frm 00101 Estimated total annual burden (hours) 25 Totals ............................................................................ sradovich on DSK3GMQ082PROD with NOTICES Frequency of response officer to determine whether they can administer treatment safely and appropriately in the SSA EHCs. Respondents are physicians of SSA employees who need to have medical treatment in an SSA EHC. Type of Request: Revision of an OMBapproved information collection. Fmt 4703 Sfmt 9990 E:\FR\FM\28MRN1.SGM 28MRN1

Agencies

[Federal Register Volume 82, Number 58 (Tuesday, March 28, 2017)]
[Notices]
[Pages 15412-15414]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-06025]



[[Page 15412]]

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SOCIAL SECURITY ADMINISTRATION

[Docket No: SSA-2017-0013]


Agency Information Collection Activities: Proposed Request and 
Comment Request

    The Social Security Administration (SSA) publishes a list of 
information collection packages requiring clearance by the Office of 
Management and Budget (OMB) in compliance with Public Law 104-13, the 
Paperwork Reduction Act of 1995, effective October 1, 1995. This notice 
includes revisions of OMB-approved information collections.
    SSA is soliciting comments on the accuracy of the agency's burden 
estimate; the need for the information; its practical utility; ways to 
enhance its quality, utility, and clarity; and ways to minimize burden 
on respondents, including the use of automated collection techniques or 
other forms of information technology. Mail, email, or fax your 
comments and recommendations on the information collection(s) to the 
OMB Desk Officer and SSA Reports Clearance Officer at the following 
addresses or fax numbers.

(OMB), Office of Management and Budget, Attn: Desk Officer for SSA, 
Fax: 202-395-6974, Email address: OIRA_Submission@omb.eop.gov
(SSA), Social Security Administration, OLCA, Attn: Reports Clearance 
Director, 3100 West High Rise, 6401 Security Blvd., Baltimore, MD 
21235, Fax: 410-966-2830, Email address: OR.Reports.Clearance@ssa.gov

    Or you may submit your comments online through www.regulations.gov, 
referencing Docket ID Number [SSA-2017-0013].
    I. The information collections below are pending at SSA. SSA will 
submit them to OMB within 60 days from the date of this notice. To be 
sure we consider your comments, we must receive them no later than May 
30, 2017. Individuals can obtain copies of the collection instruments 
by writing to the above email address.
    1. Request for Waiver of Overpayment Recovery or Change in 
Repayment Notice--20 CFR 404.502-404.513, 404.515, 416.550-416.570, and 
416.572--0960-0037. When Social Security beneficiaries and Supplemental 
Security Income (SSI) recipients receive an overpayment, they must 
return the extra money. These beneficiaries and recipients can use Form 
SSA-632-BK to take one of three actions: (1) Request an exemption from 
repaying, as recovery of the payment would cause financial hardship; 
(2) inform SSA they want to repay the overpayment at a monthly rate 
over a period longer than 36 months; or (3) request a different rate of 
recovery. In the latter two cases, the respondents must also provide 
financial information to help the agency determine how much the 
overpaid person can afford to repay each month. Respondents are 
overpaid beneficiaries or SSI recipients who are requesting: (1) A 
waiver of recovery of an overpayment, or (2) a lesser rate of 
withholding.
    Type of Request: Revision of an OMB-approved information 
collection.

----------------------------------------------------------------------------------------------------------------
                                                                                      Average        Estimated
                                                     Number of     Frequency  of    burden per     total annual
             Modality of completion                 respondents      response        response         burden
                                                                                     (minutes)        (hours)
----------------------------------------------------------------------------------------------------------------
Waiver of Overpayment (Completes Whole Paper             400,000               1             120         800,000
 Form)..........................................
Change in Repayment (Completes Partial Paper             100,000               1              45          75,000
 Form)..........................................
Regional Application (New York Debt Management).          44,000               1             120          88,000
Internet Instructions...........................         500,000               1               5          41,667
                                                 ---------------------------------------------------------------
    Totals......................................       1,044,000  ..............  ..............       1,004,667
----------------------------------------------------------------------------------------------------------------

    2. RS/DI Quality Review Case Analysis: Sampled Number Holder; 
Auxiliaries/Survivors; Parent; and Stewardship Annual Earnings Test--
0960-0189. Section 205(a) of the Social Security Act (Act) authorizes 
the Commissioner of SSA to conduct the quality review process, which 
entails collecting information related to the accuracy of payments made 
under the Old-Age, Survivors, and Disability Insurance Program (OASDI). 
Sections 228(a)(3), 1614(a)(1)(B), and 1836(2) of the Act require a 
determination of the citizenship or alien status of the beneficiary; 
this is only one item that we might question as part of the Annual 
Quality review. SSA uses Forms SSA-2930, SSA-2931, and SSA-2932 to 
establish a national payment accuracy rate for all cases in payment 
status, and to serve as a source of information regarding problem areas 
in the Retirement Survivors Insurance (RSI) and Disability Insurance 
(DI) programs. We also use the information to measure the accuracy rate 
for newly adjudicated RSI or DI cases. SSA uses Form SSA-4659 to 
evaluate the effectiveness of the annual earnings test, and to use the 
results in developing ongoing improvements in the process. About 
twenty-five percent of respondents will have in-person reviews and 
receive one of the following appointment letters: (1) SSA-L8550-U3 
(Appointment Letter--Sample Individual); (2) SSA-L8551-U3 (Appointment 
Letter--Sample Family); or (3) the SSA-L8552-U3 (Appointment Letter--
Rep Payee). Seventy-five percent of respondents will receive a notice 
for a telephone review using the SSA-L8553-U3 (Beneficiary Telephone 
Contact) or the SSA-L8554-U3 (Rep Payee Telephone Contact). To help the 
beneficiary prepare for the interview, we include three forms with each 
notice: (1) SSA-85 (Information Needed to Review Your Social Security 
Claim) lists the information the beneficiary will need to gather for 
the interview; (2) SSA-2935 (Authorization to the Social Security 
Administration to Obtain Personal Information) verifies the 
beneficiary's correct payment amount, if necessary; and (3) SSA-8552 
(Interview Confirmation) confirms or reschedules the interview if 
necessary. The respondents are a statistically valid sample of all 
OASDI beneficiaries in current pay status or their representative 
payees.
    Type of Request: Revision of an OMB-approved information 
collection.

[[Page 15413]]



----------------------------------------------------------------------------------------------------------------
                                                                                      Average        Estimated
                                                     Number of     Frequency  of    burden per     total annual
             Modality of completion                 respondents      response        response         burden
                                                                                     (minutes)        (hours)
----------------------------------------------------------------------------------------------------------------
SSA-2930........................................           1,500               1              30             750
SSA-2931........................................             850               1              30             425
SSA-4659........................................             325               1              10              54
SSA-L8550-U3....................................             385               1               5              32
SSA-L8551-U3....................................              95               1               5               8
SSA-L8552-U3....................................              35               1               5               3
SSA-L8553-U3....................................            4970               1               5             414
SSA-L8554-U3....................................             705               1               5              59
SSA-8552........................................            2350               1               5             196
SSA-85..........................................            3850               1               5             321
SSA-2935........................................            2350               1               5             196
SSA-8510 (also saved under OMB No. 0960-0707)...             800               1               5              67
                                                 ---------------------------------------------------------------
    Totals......................................          17,700  ..............  ..............           2,525
----------------------------------------------------------------------------------------------------------------

    3. Electronic Records Express--20 CFR 404.1512 and 416.912--0960-
0753. Electronic Records Express (ERE) is a Web-based SSA program which 
allows medical and educational providers to electronically submit 
disability claimant data to SSA. Both medical providers and other third 
parties with connections to disability applicants or recipients (e.g., 
teachers and school administrators for child disability applicants) use 
this system once they complete the registration process. SSA employees 
and State agency employees request the medical and educational records 
collected through the ERE Web site. The agency uses the information 
collected through ERE to make a determination on an Application for 
Benefits. We also use the ERE Web site to order and receive 
consultative examinations when we are unable to collect enough medical 
records to determine disability findings. The respondents are medical 
providers who evaluate or treat disability claimants or recipients, and 
other third parties with connections to disability applicants or 
recipients (e.g., teachers and school administrators for child 
disability applicants), who voluntarily choose to use ERE for 
submitting information.
    Type of Request: Revision of an OMB-approved information 
collection.

----------------------------------------------------------------------------------------------------------------
                                                                                Average  burden  Estimated total
           Modality of completion                Number of      Frequency  of    per  response    annual  burden
                                                respondents        response        (minutes)         (hours)
----------------------------------------------------------------------------------------------------------------
ERE.........................................       5,376,998                1               10          896,166
----------------------------------------------------------------------------------------------------------------

    II. SSA submitted the information collections below to OMB for 
clearance. Your comments regarding these information collections would 
be most useful if OMB and SSA receive them 30 days from the date of 
this publication. To be sure we consider your comments, we must receive 
them no later than April 27, 2017. Individuals can obtain copies of the 
OMB clearance packages by writing to OR.Reports.Clearance@ssa.gov.
    1. State Mental Institution Policy Review Booklet--20 CFR 404.2035, 
404.2065, 416.635, & 416.665--0960-0110. SSA uses Form SSA-9584-BK: (1) 
To determine if the policies and practices of a state mental 
institution acting as a representative payee for SSA beneficiaries 
conform to SSA's regulations in the use of benefits; (2) to confirm 
institutions are performing other duties and responsibilities required 
of representative payees; and (3) as the basis for conducting onsite 
reviews of the institutions and preparing subsequent reports of 
findings. The respondents are state mental institutions serving as 
representative payees for Social Security beneficiaries and SSI 
recipients.
    Type of Request: Revision of an OMB-approved information 
collection.

----------------------------------------------------------------------------------------------------------------
                                                                                Average  burden  Estimated total
           Modality of completion                Number of      Frequency  of    per  response    annual  burden
                                                respondents        response        (minutes)         (hours)
----------------------------------------------------------------------------------------------------------------
SSA-9584-BK.................................              69                1               60               69
----------------------------------------------------------------------------------------------------------------

    2. Statement of Death by Funeral Director--20 CFR 404.715 and 
404.720--0960-0142. When an SSA-insured worker dies, the funeral 
director or funeral home responsible for the worker's burial or 
cremation completes Form SSA-721 and sends it to SSA. SSA uses this 
information for three purposes: (1) To establish proof of death for the 
insured worker; (2) to determine if the insured individual was 
receiving any pre-death benefits SSA needs to terminate; and (3) to 
ascertain which surviving family member is eligible for the lump-sum 
death payment or for other death benefits. The respondents are funeral 
directors who handled death arrangements for the insured individuals.
    Type of Request: Revision of an OMB-approved information 
collection.

[[Page 15414]]



----------------------------------------------------------------------------------------------------------------
                                                                                Average  burden  Estimated total
           Modality of completion                Number of      Frequency  of    per  response    annual  burden
                                                respondents        response        (minutes)         (hours)
----------------------------------------------------------------------------------------------------------------
SSA-721.....................................         703,638                1                4           46,909
----------------------------------------------------------------------------------------------------------------

    3. Employee Identification Statement--20 CFR 404.702--0960-0473. 
When two or more individuals report earnings under the same Social 
Security Number (SSN), SSA collects information on Form SSA-4156 to 
credit the earnings to the correct individual and SSN. We send the SSA-
4156 to the employer to: (1) Identify the employees involved; (2) 
resolve the discrepancy; and (3) credit the earnings to the correct 
SSN. The respondents are employers involved in erroneous wage reporting 
for an employee.
    Type of Request: Revision of an OMB-approved information 
collection.

----------------------------------------------------------------------------------------------------------------
                                                                                Average  burden  Estimated total
           Modality of completion                Number of       Frequency of    per  response     annual burden
                                                respondents        response        (minutes)         (hours)
----------------------------------------------------------------------------------------------------------------
SSA-4156....................................           4,750                1               10              792
----------------------------------------------------------------------------------------------------------------

    4. Employee Work Activity Questionnaire--20 CFR 404.1574, 
404.1592--0960-0483. Social Security Disability Insurance (SSDI) 
beneficiaries and SSI recipients qualify for payments when a verified 
physical or mental impairment prevents them from working. If disability 
claimants attempt to return to work after receiving payments, but are 
unable to continue working, they submit the SSA-3033, Employee Work 
Activity Questionnaire, so SSA can evaluate their work attempt. SSA 
also uses this form to evaluate unsuccessful subsidy work and determine 
applicants' continuing eligibility for disability payments. The 
respondents are employers of SSDI beneficiaries and SSI recipients who 
unsuccessfully attempted to return to work.
    Type of Request: Revision of an OMB-approved information 
collection.

----------------------------------------------------------------------------------------------------------------
                                                                                Average  burden  Estimated total
           Modality of completion                Number of       Frequency of    per  response     annual burden
                                                respondents        response        (minutes)         (hours)
----------------------------------------------------------------------------------------------------------------
SSA-3033-BK.................................          15,000                1               15            3,750
----------------------------------------------------------------------------------------------------------------

    5. Request for Medical Treatment in an SSA Employee Health 
Facility: Patient Self-Administered or Staff Administered Care--0960-
0772. SSA operates onsite Employee Health Clinics (EHC) in eight 
different States. These clinics provide health care for all SSA 
employees including treatments of personal medical conditions when 
authorized through a physician. Form SSA-5072 is the employee's 
personal physician's order form. The information we collect on Form 
SSA-5072 gives the nurses the guidance they need by law to perform 
certain medical procedures and to administer prescription medications 
such as allergy immunotherapy. In addition, the form allows the medical 
officer to determine whether they can administer treatment safely and 
appropriately in the SSA EHCs. Respondents are physicians of SSA 
employees who need to have medical treatment in an SSA EHC.
    Type of Request: Revision of an OMB-approved information 
collection.

----------------------------------------------------------------------------------------------------------------
                                                                                      Average
                                     Number of     Frequency of      Number of      burden per       Estimated
     Modality of completion         respondents      response        responses       response      total  annual
                                                                                     (minutes)    burden (hours)
----------------------------------------------------------------------------------------------------------------
SSA-5072........................              25               1              25               5               2
Annually........................
SSA-5072........................              75               2             150               5              13
Bi-Annually.....................
                                 -------------------------------------------------------------------------------
    Totals......................             100  ..............  ..............  ..............              15
----------------------------------------------------------------------------------------------------------------


    Dated: March 22, 2017.
Naomi R. Sipple,
Reports Clearance Officer, Social Security Administration.
[FR Doc. 2017-06025 Filed 3-27-17; 8:45 am]
BILLING CODE 4191-02-P